(SOAP NOTE) NR511 Jo AGE 5 FEMALE

(SOAP NOTE) NR511 Jo AGE 5 FEMALE Chief complaint: difficult to get the children to go to bed at night and stay in bed History of present illness (HPI): The mother denies any recent illnesses in either child and reports they are here for their check-up. She does report that since moving in with her parents recently, it has been difficult to get the children to go to bed at night and stay in bed and expresses extreme frustration with this. Jo has been getting up to play in the room at night and She reports that they are eating three meals per day and two snacks, one at bedtime and one in the afternoon between lunch and dinner. Riley is still taking infant formula. Mother brushes their teeth twice a day, ride in car seats in the car, and play vigorously both indoors and outdoors at home. She also verbalizes extreme concern of their impending loss of health insurance. Past Medical History/Birth history: Full-term gestation, born cesarean section, weight. 7 pounds 4 ounces. There were no complications in pregnancy, but the mother did smoke 1 packper-day throughout pregnancy. There were no hospitalizations—NKDA Nutrition: The daily medication was chewable children’s multivitamin with iron. They eat three meals and two snacks. There is a great deal of juice, soda, and processed or quick foods given in the house. Immunizations: Birth Hep B, 2 months – DTaP, COMVAX, PCV13, IPV, 4 months - DTaP, COMVAX, PCV13, IPV, 6 months – DtaP, PCV 13, IPV. Hep B, 12 months – MMR, Varicella, Hep A, PCV 13, 18 months – DtaP, Hep A Family History: They are maternal and paternal smokers. The mother has been one since age 22 at one pack-per-day until 18 months ago. The father continues to smoke. There were no diseases reported in either parent. Kayla has a history with gestational diabetes. Mary has a history of hyperlipidemia, Type 2 DM, and Hypertension. Tom has a history of hypertension, hyperlipidemia, and an MI with stenting 2 years ago. The mother has two siblings; one who died in an MVA 5 years ago at the age of 18 a younger brother, and an older sister who is 42 and lives in a large urban city in the Midwest with her family, and she is in good health but also had PCOS and difficulty conceiving. Other family members died of old age. She is unaware of paternal familial health history. Social and environmental history: Both children currently live with their mother and maternal grandparents for the last 8 weeks. Their father is involved but lives several hours away where he works. Jo will be starting kindergarten this fall in the community’s elementary school. Cultural history: They are Latin American in descent, the grandparents emigrated from Cuba in the 1970s. Jo and Riley are United States soil. Review of Systems: Neurologic: Frequent morning headaches? Do you have any developmental concerns? Is she hyperactive while at school? Any difficulties paying attention? Irritability of mood swings throughout the day?